The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs you would expect to see the circumstances of the leave _______

documented in both the progress notes and the discharge summary

According to CPT, in which of the following cases would an established E/M code be used

Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y

An effective information governance system should include:

Disposition Retention, Availability

Discharge summary documentation must include:

Significant findings during hospitalization

Level II (national) codes of the HCPCS coding system are maintained by the

Centers for Medicare and Medicaid Services

Which classification system was developed to standardize terminology and codes for use in clinical laboratories?

Logical Observation Identifiers Names and Codes (LOINC)

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Domain 1

Question	Answer
The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs you would expect to see the circumstances of the leave _______	documented in both the progress notes and the discharge summary
According to CPT, in which of the following cases would an established E/M code be used	Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y
A process through which you reviewed a patient record and entered the required elements into a database.	Abstracting
A barrier to widespread use of automated code assignment is ____	Poor quality of documentation
An effective information governance system should include:	Disposition Retention, Availability
In ICD-10-PCS to code "freeing of vagus nerve root from surrounding scar tissue via open approach", the root operation would be"	release
Discharge summary documentation must include:	Significant findings during hospitalization
The best place to ascertain the size of an excised lesion for accurate CPT coding is the _________	operative report
Level 1 (CPT) codes of the HCPCS coding system are maintained by the	American Medical Association
Level II (national) codes of the HCPCS coding system are maintained by the	Centers for Medicare and Medicaid Services
The master patient index- must, at a minimum, include sufficient information to	uniquely identify the patient
The main difference between concurrent and retrospective coding is	when the coding is done
The most common type of registry located in hospitals of all sizes and in every region of the country is the ________	cancer registry
In ICD-10-PCS, there are how many different approached to reach the site of the procedure?	7
Which classification system was developed to standardize terminology and codes for use in clinical laboratories?	Logical Observation Identifiers Names and Codes (LOINC)
A surgeon requests the name of a patient he admitted in 2013. What would be useful to retrieve this information?	R-ADT system
Improving the clinical specificity of physician reports through a physician query is a goal shared by the coding staff and the _________	CDI practitioner
In ICD-10-PCS when the objective of the procedure is to cut off the blood supply to the vessel the root operation is	occlusion
To gather statistics for surgical services provided on an outpatient basis, which of the following codes are needed?	CPT codes
An example of a primary data source for healthcare statistics is the______.	health record
Access to radiologic images has been improved through the use of ______.	PACS

Created by: MCatherwood

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